Zoë Kessler went through the first four decades of her life thinking something must be wrong with her. When she was a child, Kessler could not understand why she kept misbehaving. “I spent a ton of time in the hall for talking and being the class clown,” she says. “My mom couldn't control me, and I couldn't control me.” In adulthood, her behavior improved, but she was so unfocused she had trouble figuring out what she should be doing minute to minute, and she struggled to complete the projects she had once been so excited about starting.
Then, at age 47, Kessler was diagnosed with attention-deficit hyperactivity disorder (ADHD). She realized that a lot of the traits that had long made her feel out of place were actually symptoms of a condition that could be treated. “I've had to rethink my entire life,” she says. “Why didn't anyone tell me?”
During Kessler's childhood, most people thought only little boys could have ADHD. Clinicians are realizing that ADHD is common in girls, too. Further, they are recognizing that restlessness is not the only smoking gun. Although Kessler was as hyperactive and talkative as stereotypical boys with the condition, now clinicians realize that many children with ADHD seem more spacey than fidgety. In fact, Kessler was relatively lucky to be diagnosed at all. In a study of mental health conditions in the U.S. published in 2006, health care policy professor Ronald C. Kessler of Harvard University (who is no relation to Zoë) and his colleagues screened 3,199 adults for ADHD, conducting follow-up interviews in 154 of them. They concluded that only one in 10 adults in the U.S. with the condition receives a diagnosis of ADHD.
That statistic most likely will improve as more researchers and clinicians acknowledge the adult form of ADHD. During the past two decades multiple studies have confirmed that the disorder can persist across a person's life span. Indeed, the latest edition of the American Psychiatric Association's diagnostic manual, the DSM-5, is the first to explicitly recognize adult ADHD, which is thought to afflict 4.4 percent of the adult population, in its description of the disorder [see box].
The need for treatment in adulthood has become increasingly apparent. Recent studies have demonstrated that the disorder can limit professional success and income, strain relationships and diminish well-being. Fortunately, research published during the past decade has shown that stimulant medication, the standard treatment for children, is also effective in adults. Yet evidence also suggests that adults with ADHD must learn new habits to overcome the numerous organizational challenges they face daily.
Researchers have devised new strategies to help these individuals plan, prioritize and organize their lives so that they can accomplish their goals, stay healthy and keep their relationships intact. Many of these techniques would also benefit the vast majority of people, given that virtually all of us could use ways to more efficiently and effectively run our own lives.
Recognizing Adult ADHD
With time, about half the children treated for ADHD recover completely. For those who do not respond fully to treatment, aspects of the disorder nonetheless change as a person matures. At all ages, people with ADHD face challenges stemming from a combination of three core symptoms: trouble paying attention, restlessness and impulsivity. By adulthood, hyperactive and impulsive traits tend to wane, whereas difficulties with controlling attention more often persist.
In some instances, ADHD may seem to show up suddenly in adulthood. In cases such as Kessler's, the symptoms are missed in childhood. Yet often the signs very likely are masked. After all, parents, educators and other adults usher children through each day, collecting their belongings, bringing them to school and activities on time, cajoling them to do homework and chores. Such supervision can compensate for a child's deficits in attending to tasks and working toward goals. As children grow up, much of that support disappears just as responsibilities accumulate, enabling previously hidden deficiencies to become all too obvious. Without parents to remind them of assignments, a college student may find his or her grades dropping dramatically. Later the demands of a job or parenthood may create complexities that a person cannot manage. As important matters fall through the cracks and sufferers become demoralized or overwhelmed, they may finally seek help, leading to a diagnosis of ADHD.
Although the pattern of difficulty varies from one person to the next, one central problem that afflicts adults is an inability to focus. They tend to have trouble getting around to, sticking with or finishing certain types of tasks. Although they can generally focus quite well on stimulating activities such as playing video games or working in a fast-paced environment such as an emergency room, they may be easily diverted from tasks that are repetitive—sorting laundry or filling out forms—or mentally challenging, such as writing a speech or term paper. Of course, a person can choose to work in a deadline-driven atmosphere that keeps them invigorated, but laundry still has to be sorted, bills paid and complex problems solved.
Impulsiveness, though often less severe in adulthood, can produce other predicaments. With short-term interests and ideas repeatedly trumping long-term goals, a person with ADHD lives a reactive rather than proactive existence. He or she may be unable to curb the urge to check e-mail or Twitter so as to focus on a challenging project. Spontaneous spending can lead to unnecessary financial burdens and bankruptcy. Sexual impulsivity can cause unwanted pregnancies, and reckless driving may result in accidents. Cutting people off in conversation or blurting out inappropriate remarks—signs of verbal impulsivity—can harm relationships.
Such reactivity, and its consequences, may stem in part from a lack of emotional control. In a study published in 2013 one of us (Surman) and his colleagues at Massachusetts General Hospital used a questionnaire to assess emotional self-regulation—a construct that includes frustration tolerance, temper and emotional impulsivity—among 206 adults with ADHD and 123 without the disorder. They found that 61 percent of those with ADHD had trouble controlling their emotional expression, overreacting with anger more often than 95 percent of those without ADHD. Such difficulty was associated with poorer quality of life, worse social adjustment in many realms, a higher likelihood of divorce (and of having never been married), and a higher risk of traffic accidents.
Many adults with ADHD also display significant problems with organization and planning. Individuals may fail to maintain a schedule, prioritize tasks and keep track of time. At work, they often struggle to finish important assignments—becoming sidetracked by minutiae—run late and spend too much time getting their work done. Sometimes their scattered lives prevent them from making it to the office at all. Results from the World Health Organization's World Mental Health Survey published in 2008 demonstrated that untreated adults with ADHD missed the equivalent of 22 more days of work than those without the condition. This underperformance may explain why adults with ADHD are often passed up for promotions and unable to reach their professional potential.
Challenges with planning and organization also lead to irregular or unhealthy patterns of self-care. Quality of sleep, which can affect health, happiness and success, is often poor in adults with ADHD. In a study published in 2009 Surman and his colleagues found that more than half of 182 adults with ADHD reported either restless sleep or difficulty getting to sleep. Those with ADHD also said they went to bed more than half an hour later, on average, than did 117 adults without the condition. Individuals with the disorder also had a wider range of bedtimes and greater daytime sleepiness, which can, of course, compound attention problems.
Pills and Skills
Reducing the frustrations and disabilities that accompany ADHD in adults usually requires a multifaceted approach that includes drug and behavioral therapy. Medication can ameliorate distractibility and impulsiveness in the 6 percent of children diagnosed with ADHD. Several studies have now shown that stimulants such as Ritalin and Concerta (both methylphenidate) or Adderall, which is a combination of amphetamine and dextroamphetamine, can improve focus and decrease restlessness in adults as well. Individuals taking medication for ADHD often report that they are better able to get around to, stick with and finish tasks.
But medication alone does not hone the more complex organizational and planning skills that help people hew to a regular routine. For example, in a clinical trial published in 2011 Joseph Biederman and his colleagues at Mass General found that 40 percent of adults who took methylphenidate for six weeks still reported significant challenges planning events and staying organized.
Thus, many adults with ADHD also need therapy to learn and practice organizational and self-regulatory skills. Individuals need different types of support, but therapists may teach them to rank items on to-do lists in order of importance, recognize what distracts them from tasks, and establish new habits, such as setting aside time for planning and prioritizing.
Adults with ADHD also often need help setting up an organizational structure—typically, a consistent location—for important objects and pieces of information. House and car keys should have a home rather than being tossed in various places. Appointments and phone numbers should similarly be entered into a calendar or contact list that is readily accessible rather than scribbled on the back of an envelope that could get lost or tossed in the trash. People may program an alarm to remind them of an appointment or to pick up the kids or use an electronic calendar that synchs with e-mail and their cell phone so they can easily enter a meeting or event as soon as they learn about it.
In a study published in 2005 psychologist Steven A. Safren of Mass General and his colleagues showed that 12 training sessions, focused on adopting organizational strategies, combined with medication, was more effective for ADHD symptoms than medication alone in 31 adults with ADHD. In a follow-up study published in 2010 Safren found that 12 weeks of training in organizational techniques relieved the burden of ADHD in 79 adult patients more than relaxation therapy of the same duration did.
Therapy can also curtail impulsive decision making. In our own clinical practices, we ask clients to pick “critical moments” in which they tend to stray from their intended course. Such a moment might be deciding to play one more video game instead of going to bed on time or hitting snooze on the alarm clock, until a person is so rushed that gym clothes are forgotten and the planned exercise never happens. Once patients become aware of the moments they go astray, we help them craft a plan for making a better choice. For example, a patient may decide to read rather than play games before bedtime or set aside a time for gaming as a reward for hard work that does not disrupt their ability to wind down from the day. If someone surfs the Web or compulsively checks e-mail at work, they might download an app that turns off Internet and e-mail access for hours.
Technology such as computer reminders, distraction blockers or planning tools can serve as “peripheral brains” to support the human brain in completing challenging cognitive tasks. People can play a similar role. An assistant might keep a calendar for you; a spouse might protect family time; a colleague might remind you of a regular meeting. Professionals, such as mental health therapists, rehabilitation specialists and ADHD “coaches,” can also keep people on track and accountable. Coaches may suggest adaptive strategies, teaching clients to prioritize and set realistic goals, among other skills.
Many adults with ADHD use support groups, such as those organized by Children and Adults with ADHD or the Attention Deficit Disorder Association, to meet and confer with others struggling with similar challenges. In these gatherings, group members can discuss their new habits and own up to their failings, a conversation that may help them stick to the strategies they have learned. In 2010 psychologist Mary V. Solanto of the Mount Sinai School of Medicine and her colleagues found that teaching organizational habits in a group setting is also effective at relieving symptoms of ADHD.
“Why Do I Keep Doing This?”
One critical component of therapy is aimed at an emotional barrier to change: a self-critical internal voice that saps the motivation to learn new skills and adopt better habits. Adults with ADHD often suffer psychologically from a sense of unfulfilled potential, the sting of criticism from others or regrets about the mistakes they have made.
“The default was that I was a bad, out-of-control kid who willfully misbehaved,” Kessler says. “My self-esteem and self-confidence were pummeled as a child.” Before her diagnosis and the hard work that followed, Kessler would often see herself as “screwing up.” “Why do I keep doing this?” she would angrily ask herself.
Cognitive-behavior therapy is based on the idea that thoughts, feelings and actions are interrelated and that changing any one of those elements influences the others. In one cognitive technique, called a thought record, a person describes a situation in which he or she experienced distress and a therapist helps that person identify how much of the distress is rational versus emotional—that is, rooted in his or her own perspective. This process can help people see the mental traps that they tend to fall into when coping with difficult situations. These snares may include catastrophizing (thinking that something is far worse than it is); mind reading (believing you know what others think of you); or taking an all-or-nothing approach toward self-worth (you are either a winner or a loser with no middle ground). Therapists help patients adopt a more rational point of view so that they can focus on problem solving. Individuals with ADHD then have the energy to come up with strategies for getting tasks done or even caring for themselves—important tasks such as eating, exercising and sleeping on a regular schedule. The behavioral interventions, such as instruction in organizational techniques and decision making at critical moments, represent another key part of this type of therapy.
For Kessler, medication, along with cognitive approaches, has transformed the way she lives. “Before, I was just too overwhelmed and couldn't really bring anything to term,” Kessler recalls. Today she uses a pen-and-paper system to keep track of appointments and the great ideas that bubble up at random times. She also does meditation to lessen her mood swings and improve her focus and time management. Being in nature similarly quiets her mind, stabilizes her mood and helps her manage her hyperactivity. She channels her drive to talk into standup comedy, public speaking and writing. Cultivating friends who are supportive helps her feel better about herself.
Her organization and stamina have improved dramatically through these efforts. Kessler's second book, part memoir, part self-help, entitled ADHD According to Zoë, was published in September, and her freelance writing and speaking careers are thriving. Emotionally, she also now understands that when she does say something inappropriate it is not necessarily a catastrophe. If she needs to apologize to someone, she does, without beating herself up about it. That way she can focus on other aspects of her life. And Kessler's improved mental and organizational discipline has reinforced her sense of self-worth. “I actually get a kick out of myself,” she says.